the benefits of inter-professional care
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The Benefits of Inter-Professional Care. Ontario Chiropractic Association www.chiropractic.on.ca [email protected]. Overview. About chiropractic Chiropractic in Ontario Evidence-based practice Recent data Models of interaction Discussion. About Chiropractic. Chiropractic Care. - PowerPoint PPT PresentationTRANSCRIPT
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The Benefits ofInter-Professional Care
Ontario Chiropractic Associationwww.chiropractic.on.ca [email protected]
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Overview
• About chiropractic
• Chiropractic in Ontario
• Evidence-based practice
• Recent data
• Models of interaction
• Discussion
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About Chiropractic
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Chiropractic Care
• Assessment, diagnosis and treatment of neuromusculoskeletal disorders resulting from conditions affecting joints, ligaments, tendons, muscles, and nerves
• Treatment and management of such conditions / disorders, primarily with the use of manual therapies including manipulation
• Nutrition, therapeutic exercise, lifestyle and ergonomic counselling and recommendations
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Chiropractic Facts: Canada
• 6,000+ regulated practitioners
• 4.5 million+ Canadians visit a DC each year
• 88% of patients between 20 and 50 years old
• Most common condition treated: musculoskeletal injuries and complaints (96%)
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Chiropractic Education in Canada
• 4 year / 4,500 hour program at accredited college(12 in North America)
– Canadian Memorial Chiropractic College (Toronto)
– Université du Québec à Trois-Rivières
• Prerequisites for admission:
– 3 years university (non specific); minimum GPA 2.5
– Actual 2003 acceptance statistics:
• GPA 3.43
• 85% Bachelors / 15% Masters
• Average age 25
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Academic Program
• First professional baccalaureate degree
• Multi-disciplinary faculty and training
– Anatomy, biochemistry, physiology, neurology, radiology, immunology, microbiology, pathology and clinical sciences linked to diagnosis
• 4th year – internship
– Multidisciplinary facilities
– Clinical rounds
– Competency based assessment
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Chiropractic in Ontario
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Chiropractic Facts: Ontario
• 3,000+ regulated practitioners
• 1.2 million Ontarians visit a DC each year
• 30% of Ontarians with joint/limb disorders
• Patient profile:
– Female ~ male
– Educated, mid-income, skilled/professional
– ~ 75% are between 20 and 60 years old
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Scope of Practice: Ontario
“The practice of chiropractic is the assessment of conditions related to the spine, nervous system and joints, and the diagnosis, prevention and treatment, primarily by adjustment, of:
Dysfunctions or disorders arising from the structures or functions of the spine and the effects of those dysfunctions or disorders on the nervous system; and,
Dysfunctions or disorders arising from the structures or functions of the joints.”
— The Chiropractic Act
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Chiropractic in Ontario
• Controlled acts
– Diagnosis
– Spinal adjustment
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Licensing and Regulation
• Licensure
– Canadian Chiropractic Examining Board (www.cceb.ca)
• Canadian National Board Exams (Written)
• Clinical Competency Examinations (Practical)
• Regulation
– College of Chiropractors of Ontario (www.cco.on.ca)
– Provincial Licensing Examination
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Distribution of complaints
Back75%
Head/Neck13%
Extremeties6%
Other6%
• Shekelle et. al., 1998– Duration: 50% <3 weeks; 25% >12 weeks– Onset: 26% significant trauma
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Treatment Modalities
37%
44%
58%
59%
70%
87%
95%
96%
Ultrasound
Electrotherapy
Traction
Hot packs/moist heat
Soft tissue therapy
Cryotherapy
Exercise
Spinal manipulative therapy
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Treatment Goals
• Acute Care:
– Relieve Pain
– Reduce muscle spasm and inflammation
– Increase flexibility
– Restore function and range of motion
– Treatment frequency reduced as progress made
• Return to normal activities of daily living as quickly as possible
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Treatment Goals
• Rehabilitation
– Stabilize
– Increase strength
– Maintain flexibility
• Prevention
– Correct habits
– Ergonomic modification
– Minimize recurrences
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Evidence-Based Practice
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What is spinal adjustment/manipulation?
• Precise procedure, generally applied by hand to the joints
• Force and technique modified to patient age, stature and condition
• Improves joint mobility by restoring the range of motion, reducing muscle hypertonicity thereby relieving pressure and tension
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Manipulation vs. Mobilization
• Stages of adjustment and definition of joint manipulation (Sandoz R.)
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Rationale for Manipulative Therapy
• Low Back Pain Trials
– Excess of 45 RCT’s
– Meta-analysis (Cochrane Collaboration)
– Systematic analytical reviews (Van Tulder, 1996)
– Multi-discipline overviews
• Rand (Shekelle 1992)
• AHCPR (Bigos 1995)
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Rationale for Manipulative Therapy
• Cervical Spine Trials
– <10 RCT’s for neck pain and SMT
– Meta-analysis (Cochrane Collaboration, 2003)
– Systematic analytical reviews (Hurwitz 1997)
– Multidiscipline overview: Quebec Task Force on Whiplash, 1995
• Evidence not as robust as for LBP
• Generalizability to LBP trials?
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Adverse Events
• Muscular soreness or stiffness– Majority of events
• Sprain / strain• Temporal Association (not necessarily causal)
– Disc injury/herniation– Rib fractures
• Associated with Osteoporosis
• Vertebral artery dissection that may lead to stroke (Infarction) associated with cervical manipulation– Estimates vary and epidemiologists report that the rarity
makes it difficult to study. – The majority of data available puts the temporal risk at 1
in 900,000 to 1 in 2,000,000
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Adverse Events
• Biomechanical studies at University of Calgary by Dr. Herzog illustrate for vertebral artery damage to occur a strain of 53% must occur while traditional cervical adjustments produce an average strain of 6% at most
• Risks are low– Lower than most alternatives for similar conditions– All healthcare procedures/interventions carry risk what maters
is that the benefit outweighs the risk– Recent CPG’s on chiropractic care clearly outline the benefits
while also providing guidelines on the risks (you may want to include executive summary of c/s guidelines at presentation)
– Profession committed to ensuring members are fully aware ( seminars, CPG’s, informational updates…) of those individuals who might be presenting with symptoms of arterial dissection and or stroke and encouraging the appropriate referral
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Evidence Summary
• Strong support for efficacy of conditions making up highest proportion of cases seen by chiropractors
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Recent Data
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Ontario WSIB
• Key findings from Program of Care for Acute Lower Back Injuries (POC for ALBI)
• Comparison of select program of care outcomes for chiropractic and physiotherapy patients
• Chiropractic patients:– Received more timely care
• Average 3 days vs. Physio: average 13 days– Returned to work earlier
• Average 9 days vs. Physio: average 20 days– Recovered more quickly
• 11% of patients required care beyond 12 weeks vs. 22% of Physio patients
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Manitoba WCB
0
10
20
30
40
50
60
70
2003 34 30 60
2005 39 35 64
MD Chiro Physio
Average days lost
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000
1999
2000
2001
2002
2003
2004
2005
Chiro Physio
Average cost per claim
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Effectiveness: US Evidence
• Archives of Internal Medicine
– “Comparative Analysis of Individuals With andWithout Chiropractic Coverage: Patient Characteristics, Utilization and Costs” (Oct 2004) Legoretta AP. Metz RD, et. al.
• Retrospective study of claims data
– 1.7 million insured workers
• 700,000 with chiropractic coverage
• 1 million without chiropractic coverage
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Legoretta & Metz
• Key findings:– Access to chiropractic care “clinically beneficial... may
also reduce overall health care costs”– Plans that covered chiropractic care saved:
• 12% in costs to treat neuromusculoskeletal disorders• 1.6% in overall health insurance costs
• Drivers:– Positive risk selection (patients)– Substitution (lower cost than traditional medical care)– More conservative (less invasive treatment profiles)– Lower health service costs (fees)
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Models of Interaction
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Indications for Referral
• Back pain/Sciatica
• Neck pain
• Headache
• Repetitive strain injuries
• Myofascial pain syndromes
– Including whiplash/WAD injuries, sports injuries, and tension headaches with myogenic triggers
• Extremity injuries/MSK disorders
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Referrals: What to Expect
• Thorough differential diagnosis
• Radiology – if necessary (14%)
• Informed consent to treatment
• Brief report back to MD on clinical findings
– Initial, update, discharge
• Outcome-based therapy
– Discharge patient after complaint resolves
– Supportive care for chronic recurrent conditions
– If patient not progressing favourably, will refer back to MD
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Collaborative Care: Patient-Centred Model
Communication
• Formal (notes, language, IT)
• Informal (calls)
• Education (rounds, seminars)
• Admin meetings
Communication
• Formal (notes, language, IT)
• Informal (calls)
• Education (rounds, seminars)
• Admin meetings
Scope of Practice
• Evidence-based care (CPG)
• Philosophy
• Musculoskeletal
Scope of Practice
• Evidence-based care (CPG)
• Philosophy
• Musculoskeletal
Service Delivery
• Access (affordable, available)
• Provider equity (pay, load)
• Care paths (triage)
• Liability
Service Delivery
• Access (affordable, available)
• Provider equity (pay, load)
• Care paths (triage)
• Liability
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Recurrance of problem- open referral
Dischargefrom care
- send note
Fully recovered
Discuss options with MD - ? supportive care
- send progess notes
Improvedbut still
symptomatic
Send note to MD- recommendations
No/poorrecovery
Care based upon CPG& response monitored
with select surveys
On initial vist DC will:- do history &exam
- determine suitability- develop plan & send report to MD
If patient is referred to DC- list of DCs provided- referral note and any
ancillary tests sent
MD
Patients with MSK Conditions
Models of Interaction:
Putting it Together
Entry points
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Discussion
For information, contact:
Ontario Chiropractic Association
200 – 20 Victoria St., Toronto ON M5C 2N8
Web www.chiropractic.on.ca
E-mail [email protected]
Phone 416-860-0070 1-877-327-2273